Provider Demographics
NPI:1780686469
Name:GUAT SY JR MD PC
Entity Type:Organization
Organization Name:GUAT SY JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GUAT
Authorized Official - Middle Name:SIA
Authorized Official - Last Name:SY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:313-271-2990
Mailing Address - Street 1:17000 HUBBARD DR
Mailing Address - Street 2:STE 700
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4205
Mailing Address - Country:US
Mailing Address - Phone:313-271-2990
Mailing Address - Fax:313-271-1698
Practice Address - Street 1:17000 HUBBARD DR
Practice Address - Street 2:STE 700
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4205
Practice Address - Country:US
Practice Address - Phone:313-271-2990
Practice Address - Fax:313-271-1698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301040071208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI020H237340OtherBCN GROUP
MI020H237340OtherBCBS GROUP
MI4079900OtherAETNA
MIDP0095OtherRAILROAD MEDICARE
MI2929938-10Medicaid
MI1780686469Medicaid
MIB45647OtherHAP
MIDP0095OtherRAILROAD MEDICARE
B45647Medicare UPIN